The impact of COVID-19 on the dermatologic care of nonmelanoma skin cancers among solid organ transplant recipients

Mean age, y, (SD) 59.14 (13.7) The impact of COVID-19 on the dermatologic care of nonmelanoma skin cancers among solid organ transplant recipients Gender Female 260 (37.2%) Male 439 (62.8%) Ethnicity Hispanic or Latino 101 (14.4%) Non-Hispanic 589 (84.3%) Unknown/other 9 (1.3%) Race American Indian or Alaska Native 11 (1.6%) Asian 24 (3.4%) Black or African American 107 (15.3%) Caucasian or White 449 (64.2%) Other/unknown 108 (15.5%) Transplant organ Heart 113 (16.2%) Intestine 1 (0.1%) Kidney 375 (53.6%) Liver 166 (23.7%) Lung 9 (1.3%) Multiple organs 35 (5.0%) Immunosuppressive treatment Azathioprine 46 (6.6%) Belatacept 75 (10.7%) Cyclosporine 106 (15.2%) Everolimus 5 (0.7%) Mycophenolate mofetil/mycophenolic acid (Myfortic) 414 (59.2%)

To the Editor: The COVID-19 pandemic disrupted the dermatologic care of solid organ transplant recipients, who are at increased risk of developing both skin cancers and COVID-19 due to their immunocompromised state. 1,2Given dermatologists' concern of skin disease progression due to pandemic-related delays in care, 3 we sought to quantify the impact of the pandemic on the surveillance and treatment of nonmelanoma skin cancers (NMSCs) among transplant recipients.
A retrospective chart review was conducted at Yale University of all solid organ transplant recipients receiving immunosuppressive therapy that were seen by dermatology between January 1, 2019, and December 31, 2021.Data were analyzed using SPSS (version 28.0.0).
In total, 699 patients were included in this study (Table I).During the 3 years, 1217 biopsies were performed, of which 557 were malignant (Table II).There was an increased number of biopsies in 2020 despite a nearly complete lack of in-person visits during early pandemic lockdown from March to May of 2020.Of the NMSCs diagnosed, 8, 16, and 22 of them were found to have high risk features during the years 2019, 2020, and 2021, respectively.There was a significantly higher proportion of high risk malignancies in 2021 (the year after pandemic disruption of care) compared with 2019 (P ¼ .02)(Table II).When analyzed by subtype, this significance was found among basal cell carcinomas (BCCs) (P ¼ .04),but not squamous cell carcinomas (P ¼ .30).
To determine trends that occurred after the initial COVID-19 lockdown, the time periods of March to December of each year were analyzed.There was no significant difference in proportion of biopsies found to be malignant (P ¼ .66)or proportion treated with Mohs micrographic surgery (P ¼ .31).However, there was a significant increase in the proportion of NMSCs treated at the time of biopsy in 2020 (P \ .001);further analysis found this increase among squamous cell carcinoma in situ (P ¼ .01)and BCC (P ¼ .02)subtypes, and skin cancers in low risk ''L'' anatomic regions (P \ .001) as defined by Mohs micrographic surgery appropriate use criteria. 4en comparing NMSCs biopsied between January and March of 2019 versus 2020, there was a significant delay to Mohs micrographic surgery in 2020 (126.0 vs 53.5 days, P ¼ .03),but there was no significant difference in postoperative defect size (P ¼ .34)or number of stages (P ¼ .39)(Supplementary Table I, available via Mendeley at https://data.mendeley.com/datasets/kjtdt5khtg/1).
A recent study found no difference in rates of NMSC during the pandemic but did not comment on high risk features. 5In our study of transplant recipients, we found a significant increase in NMSCs with high risk features in 2021; this trend was observed for both BCC and squamous cell carcinoma but only reached statistical significance for BCC.It is not clear if the increased incidence of high risk cancers was due to delayed treatment, increased detection, or other unknown factors.Of note, 2 skin cancers that were treated with electrodessication at

Table I .
Patient demographics and clinical characteristics ª 2023 by the American Academy of Dermatology, Inc. Published by Elsevier Inc.This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Table II .
Biopsies and cutaneous malignancies by year